HRSA Compliance: QI/QA Assessments

Whether preparing for your health center mock site visit or your actual HRSA Operational Site Visit (OSV), your FQHC will begin by gathering your documents. There are lists in the HRSA Site Visit Protocol as well as the HRSA Compliance Manual that can sometimes be a little confusing. One area in which we commonly get questions is regarding the “QI/QA Assessments”.

QI/QA Assessments

When the HRSA Site Visit Protocol mentions “QI/QA Assessments,” it’s often a little unclear as to what HRSA means. In some areas, these assessments are understood to be what we commonly refer to as “Peer Review” assessments. In other areas, these assessments are assumed to be reports on clinical performance metrics like the UDS metrics of Hypertension Control or Childhood Immunizations. So, what do we need to prepare?

Let’s review the different areas within the Site Visit Protocol that mention these assessments.

In the Clinical Staffing Chapter, the Site Visit Protocol asks, “Does the health center have criteria and processes for modifying or removing privileges based on the outcomes of clinical competence or fitness for duty assessments?” (SVP Chapter 3: Clinical Staffing, Element d.9).

In the QI/QA chapter (SVP Chapter 8), the SVP notes that health centers should submit for review:

• QI/QA-related operating procedures or processes that address periodic QI/QA assessments

• Sample of two QI/QA assessments from the past 12 months and/or the related reports resulting from these assessments

• QI/QA assessment schedule or calendar (SVP Chapter 8: QI/QA, “Documents the Health Center Provides”)

It then asks, “Based on the interviews and review of the job/position descriptions or other documentation, do the responsibilities of this individual(s) include ensuring QI/QA assessments are conducted?” (SVP Chapter 8: QI/QA, Element b.3.2)

It also asks, “Does the health center have operating procedures or related systems that address the completion of periodic QI/QA assessments on at least a quarterly basis? (SVP Chapter 8: QI/QA, Element c.4.6).

The SVP chapter named “Board Authority” asks, “Based on your review of board minutes, other relevant documents, and interviews conducted with the Project Director/CEO and board members, were there examples of how the board evaluates the performance of the health center based on quality assurance/quality improvement assessments and other information received from health center management?” (SVP Chapter 18: Board Authority, Element c.7.).

Quarterly Assessments of Clinician Care (Peer Review)

Element d. is labeled “Quarterly Assessments of Clinician Care” and asks,

• “Are the health center’s QI/QA assessments conducted by physicians or other licensed health care professionals? For example, by nurse practitioners or registered nurses.” (SVP Chapter 8: QI/QA, Element d.7.)

• “Are the health center’s QI/QA assessments conducted on at least a quarterly basis? (SVP Chapter 8: QI/QA, Element d.8.)

• “Are these QI/QA assessments based on data systematically collected from patient records?” (Element d.9).

• “Do these assessments demonstrate that the health center is tracking and, as necessary, addressing issues related to the quality and safety of the care provided to health center patients? For example, by initiating a new safety practice as a result of an adverse event or my increasing use of appropriate medications for asthma, early entry into prenatal care, or HIV linkages to care. (Element d.10)

For more information on Peer Review, check out our blog on the topic.

Documentation of HRSA Compliance

So, after looking at all these areas, we recommend preparing the following documentation of your compliance:

• JOB DESCRIPTION - Job Description of QI/QA Director whose responsibilities include ensuring QI/QA assessments are conducted (SVP Chapter 8: QI/QA, Element b.3.). A best practice would be to simply take this language directly out of the SVP and include it in the job description of whomever you indicate is in charge of your QI Program.

• POLICY/PROCEDURE - A policy (possibly in the health center’s Credentialing and Privileging Policy) that describes the criteria and processes for modifying or removing privileges based on the outcomes of clinical competence assessments (SVP Ch 3, d.8.). The health center should define and describe what those clinical competence assessments are and a best practice recommendation would be to tie these clinical competence assessments to “Peer Review” or the “Quarterly Assessments of Clinician Care”.

• POLICY/PROCEDURE - Operating procedures and/or related systems that address completion of periodic QI/QA assessments on at least a quarterly basis (SVP Chapter 8: QI/QA, Element c.4.). In Element c., the description seems to refer to assessments that inform the modification of the provision of health center services, as appropriate and producing and sharing reports on QI/QA to support decision-making and oversight by key management staff and by the governing board regarding the provision of health center services. There should also be language in the policy that clearly states that these assessments are shared with the Board of Directors so that the board may evaluate “the performance of the health center based on quality assurance/quality improvement assessments and other information received from health center management.” (SVP Chapter 16: Program Monitoring and Data Reporting, Element c.7.).

• POLICY/PROCEDURE - QI/QA-related operating procedures or processes that address periodic QI/QA assessments (SVP Ch 8, Documents For Review). In Element d. Quarterly Assessments of Clinician Care, the SVP states this is one of the documents to be reviewed. This is generally assumed to be the Peer Review Policy. This policy should clearly state that, “The health center’s QI/QA assessments are conducted by physicians or other licensed health care professionals (such as nurse practitioner, registered nurse, or other qualified individual) on at least a quarterly basis?” (SVP Chapter 8: QI/QA, Element d.7.); That “These QI/QA assessments are based on data systematically collected from patient records?” (Element d.8.); and, that “These assessments demonstrate that the health center is tracking and, as necessary, addressing issues related to the quality and safety of the care provided to health center patients (e.g., use of appropriate medications for asthma, early entry into prenatal care, HIV linkages to care, response initiated as a result of a recent adverse event).” (Element d.9.).

• SAMPLE - Sample of two QI/QA assessments from the past year and/or the related reports resulting from these assessments (SVP Ch 8, Documents For Review). In Element d. Quarterly Assessments of Clinician Care, the SVP states this is to be reviewed. So this is generally assumed to be the samples of peer review as outlined in the health center’s Peer Review Policy.

• SAMPLE - Schedule of QI/QA assessments (SVP Chapter 8: QI/QA, Documents For Review). In Element d. Quarterly Assessments of Clinician Care, the SVP states this is to be reviewed. So, this is generally assumed to be a schedule or calendar indicating when peer review is to be completed. A best practice recommendation would be to make a list or calendar indicating the dates of each quarterly assessment, the areas of service assessed (should cover all areas in-scope.

Please reference your most recent version of the HRSA Compliance Manual (https://bphc.hrsa.gov/programrequirements/compliancemanual/index.html) or the HRSA Site Visit Protocol (https://bphc.hrsa.gov/programrequirements/svprotocol.html).

Reviewed: March 6, 2026